Ecallantide for the acute treatment of angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter, randomized, controlled trial.

STUDY OBJECTIVE: We compare the safety and efficacy of ecallantide with placebo in subjects undergoing assessment for acute angiotensin-converting enzyme inhibitor-induced angioedema (ACEIA) in an emergency department (ED). METHODS: This was a multicenter, phase 2, double-blind study with subjects randomized to receive a single subcutaneous dose of ecallantide (10, 30, or 60 mg) or placebo plus physician-directed conventional therapy. The primary endpoint was defined as meeting predetermined discharge eligibility criteria within 6 hours of study drug administration. Discharge criteria included improvement of edema, stable vital signs, absence of stridor, absence of dyspnea or use of accessory muscles during respiration, absence of drooling, and ability to drink without difficulty. RESULTS: An interim analysis showed that a high percentage of subjects met the primary endpoint, and the study was halted. Overall, 79 subjects were randomized and 76 had data for analysis. Most had mild (45%) or moderate (42%) ACEIA. The discharge eligibility endpoint was met by 72% of the placebo group and 85%, 89%, and 89% of the ecallantide 10-, 30-, and 60-mg groups, respectively. This difference in meeting discharge eligibility endpoint criteria between treatment groups was not statistically significant. The incidence of treatment-emergent adverse events was similar between placebo and active-treatment groups. CONCLUSION: The addition of ecallantide to standard therapy does not appear to improve angioedema compared with placebo in ED patients with ACEIA. Our data suggest that most ED patients presenting with mild to moderate ACEIA are likely to meet our discharge eligibility criteria within 6 hours of treatment, regardless of intervention. Further studies to assess the utility of ecallantide in patients with more severe angioedema may be useful. No new safety signals related to ecallantide administration were identified.

"Cold feet": A qualitative study of medical students who seriously considered emergency medicine but chose another specialty.

Introduction: Emergency medicine (EM) has historically been among the most competitive specialties in the United States. However, in 2022 and 2023, 219 of 2921 and 554 of 3010 respective National Resident Matching Program positions were initially unfilled. Medical students' selection of a medical specialty is a complex process. To better understand recent trends in the EM residency match, this qualitative study explored through one-on-one interviews the rationale of senior medical students who seriously considered EM but ultimately pursued another specialty. Methods: A convenience sample of senior medical students from across the United States was recruited via multiple mechanisms after the 2023 match. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one-on-one semistructured interviews and thematic analysis of the data was performed using a constant comparative approach. Results: Sixteen senior medical students from 12 different institutions participated in the study. Thematic saturation was reached after 12 interviews but data from all 16 interviews were included for qualitative analyses. Five major themes emerged as important in students' consideration but ultimate rejection of EM as a career: (1) innate features of EM attracted or dissuaded students, (2) widespread awareness of a recent workforce report, (3) burnout in EM, (4) their perception of EM's standing in the health care landscape, and (5) early EM experience and exposure. Conclusions: This qualitative study identified five major themes in the career decisions of senior medical students who seriously considered EM but chose another specialty. These findings may help inform the perceptions of students and guide future EM recruitment efforts.

Severe blood loss anemia in a Jehovah's Witness treated with adjunctive hyperbaric oxygen therapy.

We describe the case of a 39-year-old African-American woman who developed sudden onset, near-term placental abruption with severe blood loss anemia whose religious beliefs precluded her from receiving any blood products. The patient had lost most of her blood volume, with a reported hemoglobin level of 1.9 g/dL, developed multisystem failure, and disseminated intravascular coagulation with bilateral deep venous thrombosis. Adjunctive hyperbaric oxygenation (HBO) therapy was considered, and the patient was referred for treatment. The patient required ventilatory support as well as vasopressors and hemodialysis. HBO therapy occured in a monoplace chamber setting at 2.0 atmospheres absolute for 90 minutes per treatment up to twice daily depending on patients clinical status. The patient underwent a total of 30 HBO treatments and had sustained improvement in all hemodynamic parameters, red blood cell volume, renal and respiratory function. She was discharged to a rehabilitation facility on hospital day 29 and then to home, soon thereafter. The patient had no evidence of sustained physical or cognitive impairment at time of discharge, and there were no reported complications associated with HBO therapy. Adjunctive HBO therapy should be considered in the management of patients with exceptional severe blood loss anemia who refuse the use of blood products.

State of the Science: Tools and Measurement for Shared Decision Making.

Shared decision making (SDM) has been advocated as an approach to selecting medical tests and treatments for many situations. The goal of SDM is to ensure that patients are well informed, are meaningfully involved in decisions, and receive treatments that meet their goals and preferences. There is considerable evidence about the tools used to promote SDM, called patient decision aids, and many different measures have been developed to assess the impact of SDM. However, fairly little is known about the applicability of the tools and measures in the emergency department (ED) setting. This article builds on insights from two keynote lectures presented at the 2016 Academic Emergency Medicine Consensus Conference discussing the state of the science for measurement of SDM and the design of patient decision aids to promote SDM conversations and highlights some key areas for further research to advance SDM in the ED.

Improving diagnostic accuracy of anaphylaxis in the acute care setting.

The identification and appropriate management of those at highest risk for life-threatening anaphylaxis remains a clinical enigma. The most widely used criteria for such patients were developed in a symposium convened by National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network. In this paper we review the current literature on the diagnosis of acute allergic reactions as well as atypical presentations that clinicians should recognize. Review of case series reveals significant variability in definition and approach to this common and potentially life-threatening condition. Series on fatal cases of anaphylaxis indicate that mucocutaneous signs and symptoms occur less frequently than in milder cases. Of biomarkers studied to aid in the work-up of possible anaphylaxis, drawing blood during the initial six hours of an acute reaction for analysis of serum tryptase has been recommended in atypical cases. This can provide valuable information when a definitive diagnosis cannot be made by history and physical exam.

Incorporating evidence-based medicine into resident education: a CORD survey of faculty and resident expectations.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) invokes evidence-based medicine (EBM) principles through the practice-based learning core competency. The authors hypothesized that among a representative sample of emergency medicine (EM) residency programs, a wide variability in EBM resident training priorities, faculty expertise expectations, and curricula exists. OBJECTIVES: The primary objective was to obtain descriptive data regarding EBM practices and expectations from EM physician educators. Our secondary objective was to assess differences in EBM educational priorities among journal club directors compared with non-journal club directors. METHODS: A 19-question survey was developed by a group of recognized EBM curriculum innovators and then disseminated to Council of Emergency Medicine Residency Directors (CORD) conference participants, assessing their opinions regarding essential EBM skill sets and EBM curricular expectations for residents and faculty at their home institutions. The survey instrument also identified the degree of interest respondents had in receiving a free monthly EBM journal club curriculum. RESULTS: A total of 157 individuals registered for the conference, and 98 completed the survey. Seventy-seven (77% of respondents) were either residency program directors or assistant/associate program directors. The majority of participants were from university-based programs and in practice at least 5 years. Respondents reported the ability to identify flawed research (45%), apply research findings to patient care (43%), and comprehend research methodology (33%) as the most important resident skill sets. The majority of respondents reported no formal journal club or EBM curricula (75%) and do not utilize structured critical appraisal instruments (71%) when reviewing the literature. While journal club directors believed that resident learners' most important EBM skill is to identify secondary peer-reviewed resources, non-journal club directors identified residents' ability to distinguish significantly flawed research as the key skill to develop. Interest in receiving a free monthly EBM journal club curriculum was widely accepted (89%). CONCLUSIONS: Attaining EBM proficiency is an expected outcome of graduate medical education (GME) training, although the specific domains of anticipated expertise differ between faculty and residents. Few respondents currently use a formalized curriculum to guide the development of EBM skill sets. There appears to be a high level of interest in obtaining EBM journal club educational content in a structured format. Measuring the effects of providing journal club curriculum content in conjunction with other EBM interventions may warrant further investigation.

Knowledge translation at the macro level: legal and ethical considerations.

Macro-level legal and ethical issues play a significant role in the successful translation of knowledge into practice. The medicolegal milieu, in particular, can promote clinical inertia and stifle innovation. Embracing new clinical practice guidelines and best practice models has not protected physicians from superfluous torts; in some cases, emerging evidence has been used as the dagger of trial lawyers rather than the scalpel of physicians. Beyond the legal challenges are overarching justice issues that frame the broad goals of knowledge translation (KT) and technology diffusion. Optimal implementation of the latest evidence requires attention to be paid to the context of the candidate community and the key opinion leaders therein, characterized by the "8Ps" (public, patients, press, physicians, policy makers, private sector, payers, and public health). Ethical and equitable KT also accounts for the global burdens and benefits of implementing innovation such that disparities and gaps in health experienced by the least advantaged are prioritized. Researchers and thought leaders must attend to questions of fairness, economics, and legal risk when investigating ways to promote equity-oriented KT.

Regional impact of Hurricane Isabel on emergency departments in coastal southeastern Virginia.

OBJECTIVES: On September 18, 2003, Hurricane Isabel made landfall as a category 2 hurricane over the mid-Atlantic region, generating record conditions for the region's 27 years of monitoring. The purpose of this study was to investigate the impact of the hurricane on the number and type of emergency department (ED) patient visits and its impact on hospital admission rate from the day of landfall to day 5 postlandfall. Comparisons were made with a control group, which comprised average daily ED census during the six-month period preceding landfall and the average daily admission rates for the preceding six months. METHODS: Designed as an observational cohort study, daily ED patient visits and admissions through the ED were tracked from the day of landfall to day 5 postlandfall. The study population included all ED patient visits at a six-hospital urban health care system, including a Level 1 trauma center in the coastal southeastern region of Virginia, with an aggregate annual ED volume of 261,000. Daily patient volumes, complaint categories, and admission rates were measured during the study period and compared with a control population that included average daily patient volumes, complaint categories, and admission rates at the same facilities for six months before landfall. During a 30-day postlandfall period, 63 emergency physicians on staff at the study hospitals were sent an ad hoc survey and asked to report their experiences if they worked during the study period. The survey included requests for future preparedness recommendations based on their experiences and are reported. RESULTS: During the six-month period preceding Hurricane Isabel, the average number of aggregate ED visits per day was 670. The average daily number of patient visits by complaint category included six major traumas, 483 medical complaints, 169 minor traumas, and 13 psychiatric complaints. On the day of landfall, the total aggregate ED volume was 359 (-46%), which included two (-66%) major traumas, 263 (-46%) medical complaints, 88 (-48%) minor traumas, and six (-54%) psychiatric complaints. During the subsequent four days postlandfall, there was a significant increase in average daily aggregate ED census of 840 (+25%) patient visits, which included three (-50%) major traumas, 564 (+17%) medical complaints, 263 (+57%) minor traumas, and ten (-23%) psychiatric complaints. The largest single-day increase in ED visits was day 1 postlandfall, with a 35% increase in daily volume (905 patient visits). The percentage of admissions from the ED to an inpatient unit on the day of landfall also demonstrated a significant increase (19%) compared with the control group (13%). Admission rates through the ED had appeared to normalize on day 1 postlandfall (12%). Response rate to the ad hoc physician survey by those who worked during the study period was 31.2% (10 of 32). The most common problem areas reported included communication failures, access to on-call personnel, and provider and nursing understaffing during the immediate postlandfall period. CONCLUSIONS: A significant overall reduction in ED visits by almost half the typical average volume was noted on the day of landfall (-46%). During the four days immediately following landfall, however, there was a marked increase in the overall ED census, with a particularly high increase on day 1 postlandfall. The largest complaint category increase was minor trauma (+57%). Hospital admission rates were highest on the day of landfall and seemed to return to baseline on day 1 postlandfall. These data may be useful for structuring ED personnel and hospital resource allocation to better serve its community during hurricane preparedness planning.